The Endocannabinoid System: What Nurses Need to Know, An Introduction

July 14, 2015December 15, 2017 / Carey S. Clark, PhD, RN, AHN-BC, RYT, FAAN / 11 Comments

Medical cannabis is now legal in 23 states and Washington DC, along with recreational cannabis also being legal in several states. Many patients and families are now relocating to Colorado and Washington State as “marijuana refugees” (http://www.nbcnews.com/business/consumer/marijuana-refugees-looking-new-homes-pot-legal-states-n22781), knowing they can freely and safely access cannabis as medicine in these recreational cannabis states. Nurses may still wonder, how is cannabis “medicine”?

As nurses we have a lot to learn about cannabis, including how it works in the mind-body-spirit system, and how we can best advocate for and support patients who could or do benefit from this medicine. Last spring, I witnessed a brief presentation being given to nurses around medical cannabis use, and it was obvious from the questions asked by many of the nurses that the social stigma around “marijuana” was alive and well. Would these nurses be so reluctant to accept and support medical cannabis use if they truly understood the endocannabinoid system (ECS)?

The ECS was discovered some time ago, with Dr. Ralph Mechoulam (Faukner, 2015) being a pioneer in this area in the mid-1990’s. There are 20,000+ scientific articles written about the endocannabinoid system (ECS). Though it has been many years since the discovery of this body regulatory system, most nurses likely know very little, if anything, about the ECS. Truly, this is a problem, nurses are more likely to know the xarelto lawsuit phone number by heart over the benefits of ECS.

A functioning ECS is essential to our health and well being. Endocannabinoids and their receptors are found throughout the body; in the brain, organs (pancreas and liver), connective tissue, bones, adipose tissues, nervous system, and immune system. We share this system in common with all other vertebrate animals, and some invertebrate animals (Sulak, 2015). Cannabinoids support homeostasis within the body’s system; the ECS is a central regulatory system, cannabinoid receptors are found throughout the body, and they are believed to be the largest receptor system in our bodies. Cell membrane cannabinoid receptors send information backwards, from the post-synaptic to the pre- synaptic nerve. CB1 (found primarily in the brain) and CB2 (mostly in the immune system and in the bones) are the main ECS receptors (Former, 2015), though several more are currently being studied. The exogenous phytocannabinoid THC, or the psychoactive compound in cannabis, works primarily on CB1 receptors (hence the “high feeling” in the brain), while the cannabinoid CBD works primarily with the immune system and creating homeostasis around the inflammatory response through CB2 receptors and does not have psychoactive effects. Other cannabinoids and their actions are still being studied, such as the non-psychoactive cannabinoids CBN and CBG, also found in cannabis. Our bodies react to both our own production of endogenous cannabinoids and to the ingestion of phyto-cannabinoids found in the cannabis plant, and other non-pyschoactive plants such as Echinacea. To read more about the science behind the ECS and endocannabinoid receptors, the following are excellent resources:

http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2241751/

http://www.ncbi.nlm.nih.gov/pubmed/16596770

Endogenous Cannabinoids: Endocannabinoids are the chemicals our own bodies make to naturally stimulate the cannabinoid receptors; anandamide and 2-arachidonoylglycerol (2-AG) are two well known endocannabinoids (Sulak, 2015) that are produced by the body as needed, though not stored int he body. The body produces these endocannabinoids in a similar fashion to how it produces endorphins (Pfrommer, 2015), and activities such as exercise support the endogenous production of cannabinoids. Endocannabinoids are also found in breast milk and in our skin. Alcohol interferes with endogenous cannabinoid production.

Phytocannabinoids: In general, we think of the cannabis plant as the generator of exogenous cannabinoids that we can ingest in a variety of ways, namely psychoactive THC (works with the CB1 receptors in the brain- and also in the gut) and non-psychoactive CBD (works with the CB2 receptors in the immune system and the gut). Other plants such as Echinacea also produce non-psychoactive cannabinoids and work with the ECS to support health and well being through homeostasis (Sulak, 2015).

Cannabinoid Deficiency Syndrome: It should be clear that everybody makes cannabinoids and everybody needs cannabinoids to function. People who do not make enough cannabinoids need to supplement with exogenous cannabinoids through cannabis ingestion, in much the same way that an diabetic needs insulin supplementation making it a “Natural Energy Powder,” in which it is good for your health. Dr. Ethan Russel’s (2004) publication on Clinical Endocannbinoid Deficiency explains this particularly well: http://www.nel.edu/pdf_/25_12/NEL251204R02_Russo_.pdf

Homeostasis:

Cancer: “Cannabinoids promote homeostasis at every level of biological life, from the sub-cellular, to the organism, and perhaps to the community and beyond. Here’s one example: autophagy, a process in which a cell sequesters part of its contents to be self-digested and recycled, is mediated by the cannabinoid system. While this process keeps normal cells alive, allowing them to maintain a balance between the synthesis, degradation, and subsequent recycling of cellular products, it has a deadly effect on malignant tumor cells, causing them to consume themselves in a programmed cellular suicide. The death of cancer cells, of course, promotes homeostasis and survival at the level of the entire organism” (Sulak, 2015, paragraph #7). Cannabinoids support apoptosis and suppress cancer tumor angiogenesis (McPartland, 2008).

Heart disease: Additionally, it has been stated that the ECS plays an important function in protecting the heart from myocardial infarction and cannabinoids can have anti-hypertensive effects (Lamontagne et al, 2006).

Inflammation: When inflammation occurs, the ECS helps to stop the process, similar to applying the brakes on a car. This is why cannabis is proving to be good medicine for inflammatory related illness. “Activation of CB₂ suppresses proinflammatory cytokines such as IL-1β and TNF-α while increasing anti-inflammatory cytokines such as IL-4 and IL-10. Although THC has well-known anti-inflammatory properties, cannabidiol also provides clinical improvement in arthritis via a cannabinoid receptor–independent mechanism” (McPartland, 2008).

PTSD: “This review shows that recent studies provided supporting evidence that PTSD patients may be able to cope with their symptoms by using cannabis products. Cannabis may dampen the strength or emotional impact of traumatic memories through synergistic mechanisms that might make it easier for people with PTSD to rest or sleep and to feel less anxious and less involved with flashback memories. The presence of endocannabinoid signalling systems within stress-sensitive nuclei of the hypothalamus, as well as upstream limbic structures (amygdala), point to the significance of this system for the regulation of neuroendocrine and behavioural responses to stress. Evidence is increasingly accumulating that cannabinoids might play a role in fear extinction and antidepressive effects. It is concluded that further studies are warranted in order to evaluate the therapeutic potential of cannabinoids in PTSD.” (Passie et al, 2012).

Seizures: Most hopeful, cannabis has been used to support pediatric treatment-resistant epilepsy, and while more research needs to be done in this area, many parents are becoming medical marijuana refugees by moving to states where they can procure cannabis for their children who suffer from seizures.

Co-agonists:Cannabis increases the pain relieving effects of morphine, as discovered by researchers at UCSF. The two medications are synergistic, and this provides great hope for patients suffering intractable pain at end of life, chronic pain suffers, and opiate addicts. (http://www.maps.org/research-archive/mmj/Abrams_2011_Cannabinoid_Opioid.pdf)

For Nurses: So as nurses, what do we need to know to support patients who use cannabis?

Legal issues: If you live or work in a state that has legalized medical or recreational use of cannabis, familiarize yourself with the laws in that state, as well as your own workplace policies around supporting patient’s use of medical cannabis. Patients may have questions and as a patient advocate, your responsibility is to support patients with their knowledge and use of this medicine within the confines of your practice setting and state laws. You should also be aware of constraints around your role as a nurse in supporting patient use of medical cannabis. For instance, Kaiser patients in some states are likely to be removed from chronic pain patient programs if they test positive for cannabis. Nurses with knowledge around the benefits of medical cannabis can also advocate to support shifts in such policies will no longer align with the emerging ECS science.

Safety: This goes along with the legal aspects; medical cannabis patients should be supported in how to manage and store their medications with safety. While cannabis is known to be extremely safe (far safer than opiates and alcohol), cannabis consumers still need to store medication out of reach of children and pets. They should be supported in knowing the safety of driving or operating machinery if they consumer THC- based cannabis medicines. They also may need information on cannabis testing for both THC: CBD ratios, pesticides and/or other hazardous materials. Many patients need assistance with the basics around medical cannabis use, such as dosage, ratios of THC: CBD, strain information, and ingestion methods.

Overcoming Stigma: Unfortunately, a stigma was created around around cannabis during the process of prohibition in the 1930’s, which was largely financially and racially driven. Contradictory state and federal laws, and the stigma around smoking cannabis (though many cannabis patients can now get relief from vaporizing using the best vape pen for oil, drinkable tinctures, topicals, wearable patches, and edibles), along with a clear ignorance around the body’s ECS, serve to further the stigma associated with medical cannabis. Educate yourself on the roots of the prohibition of the medicine:

http://origins.osu.edu/article/illegalization-marijuana-brief-history

And other issues around stigma and cannabis myths:

http://alibi.com/feature/48426/Erasing-Stigma.html

http://sandiegofreepress.org/2014/05/12-of-the-biggest-myths-about-marijuana-debunked/

http://www.huffingtonpost.com/mary-hall/weed-the-people-movie-loo_b_5501864.html

American Cannabis Nurses Association: There are many nurses actively involved in supporting the use of medical cannabis and the defining the nurse’s role in this process. The ACNA has a mission to advance excellence in cannabis nursing practice through advocacy, collaboration, education, research, and policy development. http://americancannabisnursesassociation.org/

In Israel, nurses actively support patients in cannabis consumption from the process to the dosage.

http://www.tabletmag.com/jewish-news-and-politics/137423/medical-marijuana-kibbutz

Nurses’ supporting patients healing process through cannabis medications may someday be common place in the USA as well.

References:

Lamontagne, D., Lepicier, P., Lagneux, C. & Bochard, J.F. (2006). The endogenous cardiac endocannabinoid system: A new protective mechanism against myocardial ischemia. Arch Mal Coeur Vaiss.,99(3), 242-6.

McPartland, J.M. (2008). The endocannabinoid system: An osteopathic perspective. The Journal of the American Osteopathic Association, 108, 586-600. Retrieved from http://jaoa.org/article.aspx?articleid=2093607

Passie, T, Emrich, H.M., Karst, M., Brandt, S.D., & Halpern, J.H. (2012).Mitigation of post traumatic stress symptoms by cannabis resin: A review of the clinical and neurobiological evidence. Drug Test Anal. 2012 Jul-Aug;4(7-8):649-59. doi: 10.1002/dta.1377. Retrieved from http://www.ncbi.nlm.nih.gov/pubmed/22736575.

Pfrommer, R. (2015). A beginner’s guide to the endocannabinoid system: The reason our bodies so easily process cannabis. Retrieved from http://reset.me/story/beginners-guide-to-the-endocannabinoid-system/.

Russel, E. (2004). Clinical Endocannabinoid Deficiency (CED): Can this concept explain therapeutic benefits of cannabis in migraine, fibromyalgia, irritable bowel syndrome, and other treatment resistant conditions? Neuroendocrinology Letters(25), 1-2, 31-40.

Sulak, D. (2015). Introduction to the endocannabinoid system. Retrieved from http://norml.org/library/item/introduction-to-the-endocannabinoid-system.

The Light and Dark of Nursing: Our Shadow, Part II

September 8, 2014 / Carey S. Clark, PhD, RN, AHN-BC, RYT, FAAN / Leave a comment

I have heard from many folks that they enjoyed the Part I of this blog series, which looked at some of our deep, and most scary, shadow issues in nursing; namely how a serial killer nurse can work in a healthcare system for years before being brought to justice and how the system failed to protect patients.

While this was likely one of our most extreme cases of complex shadow issues (there are a few more serial killer nurses out there, though thankfully they are low in number) and certainly many healthcare systems and administrations are in need of reform, there are also some very serious “everyday” shadow issues that nursing needs to shine the light upon in order to transform the profession. As we shine the light on our dark side, our shadows, we can begin to move out of denial of our professional issues; hence we can also begin to look for creative solutions and transformational change opportunities.

We experience challenges with the transformation of nursing practice: why is it taking us so long to take back our practices; to be able to practice nursing as a caring, compassionate, and healing art; to practice nursing qua nursing; why does it feel like we are stuck in a dark night of the soul in nursing?. We, as a professional group, have yet to really look at our own shadow projections. Theoretically, it could be that once we recognize our own shadow, the hard work is done; then we can observe, acknowledge, witness, accept and integrate these issues. This would mean less doing and fixing for our profession; we could practice presence and being with where we are at right now during these challenging times, as we look toward where we would like to be and discover how we might get there.

Below are some shadows in the profession that may be worth examining, recognizing, and witnessing. Growing awareness, being with, and bringing our collective nursing consciousness toward recognition can help move us out of states of professional oppression. Please feel free to consider and share any nursing and healthcare shadows you experience in your workplace as well!

Cognitive stacking shadow: Boynton and Hall (2012) wrote an informative post about how complex and demanding nurses’ work is from the viewpoint of our complex duties and decision making processes. Nurse Overload: The Risks to Employees and Patients .

This is worth a read to get the basics around how our workplace environments overload us with information, data, and distractions at the risk of our own and our patients’ health and safety issues. The problem here is that while systems know that this sort of overload leads to job dissatisfaction, loss of nurses, and risks to patient safety, systems and nurses seem to be doing little to no research on how to change these issues. This is costly on many levels, and perhaps nurses need to also look into how we can create new workplace environments that support our own and our patients’ well being. Cognitive stacking leads to overload and initiates the stress response, which is our next shadow to shine some light upon.

Stress response shadow: Nurses are stressed out: we work in stressful environments and we often tend to put others’ needs in front of our own, somehow failing to recognize that a) our stress has a direct impact on the stress and healing capacity of those we care for, b) we can’t keep giving without taking time to recharge, rejuvenate, and care for ourselves and c) stress is impacting our own health and well being (Clark, 2014).

The stress shows up in obvious patterns that nurses have created. I have been asked many times why so many nurses are obese. Is this a shadow issue for us as nurses, the ones who know the damage obesity causes in our bodies? Despite knowing the health issues associated with obesity, up to 54% of nurses are overweight or obese (Miller, Alpert, & Cross, 2008). Most nurses in this particular study were not motivated to make changes in their lifestyle, despite knowing the health risks of obesity.

Students often tell me they are overweight because they don’t have the time to exercise, prepare meals, eat right, sleep well, drink water, etc. Somehow the healthcare system (12 hour shifts? lack of access to healthy foods? high cortisol levels related to stress?) creates a stressful environment for us, and somehow we fail to recognize the impact this stress has on our bodies, and that we need to manage this stress or suffer the consequences. The average nurse gets only about 6 hours of sleep before any given shift, and this has great impacts on health as well as ability to function as strong clinical decision maker hour after hour (Clark, 2014). This medscape article clearly delineates the issues we face around sleep and the impact it has upon us:A Wake up call for nurses: Sleep Loss, Safety, and Health.

Stress contributes as well to many of other shadow issues: lateral violence, the nursing shortage, and our own poor health states. Letvak, Ruhm, & Lane, (2011) found that nurses will work when they are sick, and unfortunately we have higher rates of eating poorly, smoking cigarettes, abusing drugs and alcohol… and we can tend to overwork or engage in workaholic type activities (Burke, 2000).

Time and again, I hear tales from ASN through PhD prepared nurses about how they suffered PTSD from the nursing school experience, and we know that PTSD is a hazard of being a nurse: up to 14% of all nurses meet the criteria for PTSD, while as many as 25%-33% of nurses in the critical care and emergency settings screened positive for symptoms of PTSD (Mealer et al, 2007; Laposa, Alden, & Fullerton, 2003).

We know about these issues and yet both nursing academia and the systems in which we work tend to turn a blind eye toward the reality of the nursing profession’s risks and deep challenges toward health and managing our professional stress. Every healthcare facility and every school that educates nurses should be striving to shine the light on these shadow issues, and look toward finding ways to help support the health and stress management capacity of nurses. This becomes an ethical issue when we consider how the stress of the nurse can impact the stress and healing process of patients; the nurse in stress response adds to the stress of the patient’s environments, potentially right down to the neurological stress response of the patient (Clark, 2014).

Shadow Side of Caring: Most nurses likely became nurses because they care about others, they want to support healing, and they want to make a difference in others’ lives. Unfortunately, nursing school in general does not prepare new graduate nurses for the challenge of creating caring-healing environments in the face of stressful workplace demands (Clark, 2014). Every nurse educator should be concerned about providing students the tools needed to manage stress in order that they make sound clinical decisions and maintain patient safety; and also that they might fulfill their life’s calling toward caring. This is an ethical obligation, and yet our academic environments tend to be initiation grounds for living through stress while students are not adapting adequate tools to manage stress.

There is also a lingering professional shadow that creating caring-healing environments takes time, we can’t possibly have time to care for and be with patients, when we have too much to do, too many demands, too many distractions, too much cognitive stacking, too little support, too few nurses, too much stress, etc. When we buy into the truth of this idea, there may no longer be a motivation to attempt to truly care for the patient. Additionally, many healthcare facilities, including magnet facilities, and systems may claim to support nurses in caring, and yet the reality of the workplace remains unchanged, even when changes have been claimed by administration. We may call this lack of support to realize our deepest call toward caring a form of oppression by the system (Clark, 2002, 2010). A concern I have is that oppression of nurses goes unrecognized by the profession in general, and as the largest number of healthcare providers, we seem to remain in the shadow of our own power, failing to recognize how we might begin to negotiate what is nurses do in systems and how we do it (Clark, 2002; 2010).

Shadow of Oppression

Oppression of the nursing profession may likely for many nurses have it’s shadow base in academia (Pope, 2008). As Pope (p. 21) so clearly defined oppression:

“Freire defined oppression as the imposition of one person’s (or group’s) choice upon another in order to transform an individual’s consciousness to bring it in line with the oppressor’s. Prescription of thoughts, values, and behaviors are the basic elements of oppression (Freire, 1970; Rather, 1994). A behavior that is symptomatic of oppression is horizontal violence. It is the exercise of power against people in the same oppressed group. It is overt and covert non-physical hostility, such as criticism, sabotage, undermining, infighting, scapegoating and bickering (Hamlin, 2000; Duffy, 1995)”. For many of us, these experiences of oppressive behaviors and horizontal violence began in nursing school, propelled by both faculty and students alike. Yet, most of us remain unaware that what we are experiencing, the bullying, the anger, the backstabbing, are clearly symptoms of oppression. Hence the cycles continue until we take the brave steps toward shining the light on these issues.

Pope (2008) goes on to illuminate how in the shadow of oppression, the oppressed become the oppressors; she suggested it is only through a recognition of the world of oppression, reflecting and acknowledging the reality of our socio-cultrual and political worlds, that we can begin to take action against the oppressive elements of reality and also recognize our own role in our own oppression.

The problem is that failing to address this in academia, we send nurses out into the workplace who have come to either deny oppression or conversely accept it as the norm; we may have new and seasoned nurses who lack the capacity to reflect upon these issues and their origin, rather generally accepting them “as the way things are”. As Marks (2013) found in her work with nurses at a Magnet hospital, while the nurses felt empowered with their work with patients, they knew they were experiencing a lack of empowerment within the healthcare system, but they were not aware of this as a form oppression.

Conclusion

This blog is simply the tip of the iceberg; the challenge remains for us in nursing to begin to examine our shadow issues, to be open and reflective toward our own roles in oppression, despite the discomfort this brings. We need to have scholars, researchers, theorists, and bedside nurses reflecting upon oppression. How did oppression in nursing begin, how has it evolved over the years, what are our next steps toward freedom through integrating the shadow? Are we ready to free ourselves from this oppression, choosing to not be like the oppressors, and transforming the oppressive nursing professional role toward one of nursing qua nursing: namely caring, holism, and healing?

References:

Boyton, B. & Hall, D. (2012). Nurse overload: The risks to employee and patients. Retrieved from http://www.confidentvoices.com/2012/10/23/nurse-overload-the-risks-to-employee-and-patient/

Burke, R. (2000). Workaholism in organizations: Psychological and physical well-being consequences. Stress and Health, 16(1), 11-16.

Clark, C. S. (2002). The nursing shortage as a community transformational opportunity. Advances in Nursing Science, 25(1), 18-31.

Clark, C.S. (2010). The nursing shortage as a community transformational opportunity: An update. Advances in Nursing Science, 33(10), 35-52.

Clark, C.S. (2014). Stress, psychoneuroimmunology, and self-care: What every nurse needs to know. Journal of Nursing and Care, 3, 146.

Laposa, J. M., Alden, L. E., & Fullerton, L. M. (2003). Work stress and post-traumatic stress disorder in ED nurses/personnel. Journal of Emergency Nursing, 29(1), 23-28.

Letvak, S., Ruhm, C. & Lane, S. (2011). The impact of nurses’ health on productivity and quality of care. Journal of Nursing Administration, 41(4), 162-7.

Marks, L.W. (2013). The emancipatory praxis of integral nursing: The impact of human caring theory guided practice upon nursing qua nursing in an American Nurses Credentialing Center Magnet Re-designated healthcare system. Retrieved from http://media.proquest.com/media/pq/classic/doc/3073838521/fmt/ai/rep/NPDF?_s=HaGBMdTxvziM7lbtbb%2FHTWouZWo%3D

Mealer, M., et al. (2007). Increased prevalence of post-traumatic stress disorder symptoms in critical care nurses. American Journal of Respiratory and Critical Care Medicine, 175(7), 685-7.

Miller, S.K., Alpert, P.T., & Cross, C.L.. (2008). Overweight and obesity in nurses, advanced practice nurses, and nurse educators. Journal of the American Academy of Nursing Practice, 20(5), 259-65.

Pope, B. D. (2008). Transforming oppression in nursing education: Towards a liberation pedagogy. Retrieved from http://libres.uncg.edu/ir/uncg/f/umi-uncg-1639.pdf
8.

The Light and The Dark of Nursing: Our Shadow, Part I

August 13, 2014 / Carey S. Clark, PhD, RN, AHN-BC, RYT, FAAN / 2 Comments

I love nursing and I love being a nurse. That is what makes this post so challenging to write, admitting that the profession where my heart sings, where I have grown and evolved over the last twenty years, has a dark side. But if we take the advice of Jung, we come to realize, perhaps, that the shadow, the dark parts that we may try to hide or deny, needs to be acknowledged and integrated. We can learn to be loving and kind toward that which was previously denied or rejected. By shining a light on the dark places, we can invite those hidden areas to come out fully, to open up to our secrets and our darkness. While we usually think of shadow work as an individual challenge, the profession of nursing could grow and evolve from examining our shadow, from shining a light upon our darker sides.

The Shadow: Nursing in the Media

I recently read the book “The Good Nurse”by Charles Graeber. I remember listening to NPR and hearing about the book when it was released and being very upset that a book about a nurse serial killer was given such a title. To listen to what I heard on the radio in April 2013, visit this link:

The Good Nurse, NPR

It took me a year to work up to the challenge of reading the book, as I was so upset about the title alone, let alone the interview. Who was this outside journalist who came to investigate these horrendous acts, surely he did not understand nursing if he named the book in this manner. My own anger at the title of the book and the horrific situation should have been clue to me right there that I had something to face here, at least according to shadow theory. Still, I thought a book called the Good Nurse should be all about the good nursing does, not about this outlier who murdered perhaps dozens of patients. Why not call this book, “The Worst Nurse EVER”? or “The Abhorrent Nurse?”

What I didn’t realize at the time was that this book has an important message to deliver, an important message not just about Charlie Cullen, the RN who killed many, many patients, but about the whole healthcare system, about the dark side of medicine for money and the need to protect hospitals’ revenue stream dominating over the need for patient safety. I finally purchased the book and settled into reading it over spring break 2014. About half way through reading the book, I contacted the author, Charles Graeber through email and began a dialogue about the book and his choice of the title. And I was surprised to find that Graeber was beyond generous in his responses to me, helping me to shine the light, expanding it further into this dark tale.

The story is about flaws in our reporting systems, about flaws in how nurses respond, report, react to concerns for patient safety, and about flaws in quality assurance. The book is about a call for justice, for action to be taken against the healthcare systems and the specific individuals who perpetuated Cullen’s killing spree by failing to act. There is no statute of limitations with murder charges, and healthcare administrators who knowingly supported the continuing practice of a murdering nurse may perhaps be found liable on some level for the many murders that occurred after knowledge of, or even suspicions of. multiple murders were not adequately addressed. You can read my full review of the book here:

http://www.amazon.com/review/R38G2SH63CBCVG/ref=cm_cr_pr_perm?ie=UTF8&ASIN=B004QX078C

Although we can clearly see Cullen carried a deep shadow with him into nursing, that he suffered from some sort of mental illness to have had these deep killing compulsions, that he was a manipulator or sorts who could put up a front as a hard working hero nurse, we have the obligation to also see what worked in the system, and identify the shadows that need to be addressed.

What worked, where was the light? The hero-nurse who helped to indict Cullen, the investigators who did not give up or turn a blind eye, and the penal system were the lights in this issue.This book itself also becomes a beacon to shed some light on the issue.

What did the light reveal about this looming shadow in nursing, what can we learn from this media portrayal of a nurse carrying a gigantic shadow? Perhaps we can consider if academia may have some issues with screening students; that some nurses may consider a nurse who works a lot/takes the hard patients/ and makes the coffee to be a “good” nurse; that QA/QI/surveillance issues around safety as related to nursing practice and competence is apparent; that nurses may have not been empowered to take action when their suspicions arose; and that systems failed in protecting patients through monitoring and reporting.

By increasing our awareness of shadow, dark side incidents such as this obvious one, we can begin to create change and perhaps prevent future devastation. While this is an extreme example of a shadow in our beloved profession, the next entry or Part II will examine some less extreme shadow issues and Part III will focus on actions we can all take to shine the light into darkness and further support our autonomy and evolution as a caring- healing profession.

Dreaming in nursing

April 28, 2013 / Carey S. Clark, PhD, RN, AHN-BC, RYT, FAAN / 3 Comments

I woke up at 0430 this morning with my heart pounding. Occasionally this happens, I have a “nightmare” about nursing.

In this particular dream, I was working a night shift and at the end of the shift I was chatting with the nurses. I was getting ready for report, and I couldn’t remember seeing any of my patients; no names, no faces, no recollection at all. I began to feel anxious and I asked one of my fellow nurses, “Gee I hope I finished my charting” and she replied, “No I don’t think you closed out your charts.”

In a panic I ran to the charts. Of course in the dream they were not electronic, they were huge paper charts, perhaps as big as they could be about 6 inches thick, with hand written notes. I was trying to decipher the handwriting and figure out what was going on with a particular patient. As I read through the chart I realized I had not assessed this patient. I must have slept through entire shift. How could that be? Clearly from the diagnosis this patient would have needed pain medication, turning, toileting, and so on. Who was caring for this patient? I had nothing to chart and I realized that I would, at this last hour, have to go and check on all of my patients, assess them, check their meds, and then chart. My 5-year-old daughter arrived in the dream and wanted to play and I had to tell her no.

Somehow, I woke up and had to convince myself it was just a dream, nobody was harmed, I was safe in my bed. For the record, I haven’t work the floor since the late 1990’s, though I worked as a hospice nurse and taught clinical in the hospital until 2005. Around that time, I finished my PhD, and began to focus on just honing my skills as an educator while I had two babies and raised them into young children.

I have this type of dream several times a year. I suppose I could do a dream analysis, look for the Jungian archetypes, or focus on my own life-anxiety and how it is related to my work. But I am really wondering about here is the dreams that nurses have: the good, the bad, the sleep time dreams, and the awakened dreams.

What is it that our hearts desire in our practice? What are we “dreaming of” in nursing practice and education… and how do we get there? Do we find reward in a broken healthcare system and as the largest providers of healthcare in the nation, how do we take back our practices of caring and compassion? How do we partner with others to create change? How can we use the Nurse Manifesto created by Peggy Chinn, Richard Cowling, and Sue Hagedorn to our benefit?

I would love to hear nurses’ stories about what they desire. I myself wrote a story about what nurses experiencing versus what we desire and you can read about that here: https://nursemanifest.com/research_reports/2002_study/nurse65x89.htm

This story was recently published in Creative Nursing journal. I am also presenting this story and supporting nurses in creating a personal plan of action at the American Holistic Nurses Association Annual Conference in Virginia Beach, VA this June. I hope to see you there!

Language in Nursing Practice

January 29, 2013January 4, 2017 / Jane K. Dickinson / 7 Comments

I have found myself on a journey that I can no longer avoid. In 1992 I gave an inservice on language to a group of staff nurses on a pediatric unit in a large, teaching hospital. I was then a student in an MSN program (Pediatric Clinical Nurse Specialist Track). The focus of my talk was refraining from calling patients by their diagnosis (the “appy” in room 3 or the “sickler” in room 25, etc.).

I have since chosen a career in diabetes education and management, and twenty years later I am amazed at how often I see and hear the word “diabetic.” I was giving an inservice (on diabetes) to nurses who provide staff education and was amazed at how many negative and judgmental words I heard. Open up any journal, book, magazine, blog, and it’s impossible to avoid seeing this kind of language.

The health care system has been trying to evolve for years (giving some credit here), from one that is paternalistic, controlling, and about healing the sick, to one that is accepting, supportive, patient-centered and about preventing disease. From one that is about the provider to one that is about the patient. But we are not there yet. And our language is, in my opinion, one of our biggest barriers. We need to talk the talk before we can walk the talk.

Words that come to mind include “compliance,” “must,” “should,” “have to,” “need to,” “I want you to…,” non-compliant,” any word that labels a patient (diabetic, asthmatic, leukemic, sickler, and so on), “control,” “good/bad,” and many more that I can’t think of at the moment.

I truly believe that words matter. Even the most caring nurses use words/phrases that hurt – mainly because they “grew up” using them, and often because it’s just faster and easier to use them. But patients deserve to hear words that build them up (strength-based) and put them at the center of their care (patient-centered). Patients deserve to be thought of, approached, and addressed as human beings with a lot more to them than a disease, illness, infection, procedure, or what have you. And it’s true for conversations about patients as well (for instance, at the nurses station or during report).

Those of you who work in health care settings probably (undoubtedly) hear these and more words/phrases every day. You may even have become immune to them. Can I ask a big favor? Can you pay close attention in the upcoming days/weeks, and jot down any judging, negative words/phrases you hear? Could you then come back to this blog and post the words in the comments section? Thanks for your help with this little project! I would also love to hear your thoughts on how we can change the language that is used in health care.